Abstract

The purpose of this investigation was to assess college and university condom distribution programs nationwide using constructs of the Transtheoretical Model, the Health Belief Model, and the Diffusion of Innovations Theory.Using a cross-sectional design, the authors mailed and emailed a questionnaire to a geographically diverse group of 1,101 colleges and universities. Health center directors or other appropriate employees representing 438 (39.8% response rate) schools agreed to participate. The majority of schools that offer condoms to their student populations were in the maintenance stage and have hosted a program for more than 10 years. Both the institutional benefits and barriers constructs were statistically significant predictors of condom programs, OR = 1.740, 95% CI = 1.519-1.994, p < .001, and OR = .598, 95% CI = .494 - .724, p < .001, respectively. The most common institutional benefit associated with programs included reduction of sexually transmitted infections (96.6%) and encouragement of healthy student behaviors (94.2%). Among institutions that do not offer condoms to students the most prevalent institutional barriers included religious affiliation-based objections (78.3%) and institutional ideology (51.7%). Expense of condoms (30.7%) and lack of available funds (29.1%) were the most common barriers among schools that host a program. Nurses (77.0%), student peer educators (73.8%), and health center directors (72.8%) were the most commonly reported university employees involved with condom issues on campus. The mean number of condoms distributed to students/year was significantly correlated to the total student population, r(342) = .451, p < .001, the number of health center employees, r(342) = .525, p < .001, and institutional complexity, r(342) = .630, p < .001. The use of a multi-level theoretical assessment revealed unique insights into distribution efforts, benefits and barriers to programming, and prevalence of employees who participate in programs or serve as advocates for condom availability. Findings provide a critical step towards the development of benchmarks for colleges and universities nationally and identify the need for additional focus upon the influence of campus demographics, employee infrastructure, and policies upon condom availability.

Introduction

Male condoms are commonly used by young adults and college students to prevent unintended pregnancy and sexually transmitted infections (STIs; American College Health Association [ACHA], 2013; Reece et al., 2010). According to a national assessment of condom acquisition patterns by men in the U.S., those who acquired free condoms received them from settings common to universities including health clinics (20.5%), health fairs (13.4%), dorms/student groups (13.4%), and classrooms (3.6%; Reece, Mark, Schick, Herbenick, & Dodge, 2010). Over the last 12 years, several empirical studies assessing sexual behaviors among students have identified condom errors and problems as important epidemiological risk factors (Crosby, Sanders, Yarber, & Graham, 2003; Crosby, Sanders, Yarber, Graham, & Dodge, 2002; Crosby, Yarber, Sanders, & Graham, 2004; Sanders et al., 2012; Yarber et al., 2007; Yarber, Graham, Sanders, & Crosby, 2004). Condom availability is an important contextual factor for condom use among adolescents (Boldero, Moore, & Rosenthal, 1992) and college students (Crosby et al., 2003; Crosby et al., 2002; Kashima, Gallois, & McCamish,1993). A study conducted by Crosby and colleagues (2003) assessing condom use and condom-related problems among 158 college students found 42.4% of participants wanted to use a condom but did not have one available and 17.6% had a problem with a condom during sexual activity and did not have a secondary condom available.

Condom distribution programs are structural-level public health interventions that extend beyond the individual’s personal risk by addressing access to condoms within given environments (Centers for Disease Control and Prevention [CDC], 2010). According to the CDC, wide-scale distribution is an important programmatic consideration for effective condom distribution interventions (2010). In the U.S., condom distribution programs have been used to increase availability in school settings (Blake et al., 2003; Guttmacher et al., 1997) and
large-scale community-based distribution initiatives have been effective in increasing availability in New York City and Washington D.C. (CDC, 2010). A recent meta-analysis of 21 condom distribution programs by Charania and colleagues (2010) revealed significant intervention effects upon condom use, condom acquiring/condom carrying, delayed sexual initiation among youth, and reduced incidence of STIs. Additional findings indicated programs which incorporated individual and community-level considerations were more effective than those which only focused upon structural components. Various assessments have indicated condom distribution programs are cost effective (Bedimo, Pinkerton, Cohen, Gray, & Farley, 2002; Charania et al., 2010; Kirby et al., 1999; Schuster, Bell, Berry, & Kanouse, 1998).

The majority of colleges and universities in the U.S. distribute condoms to their student populations (Butler, Black, & Coster, 2011a; Eastmann-Mueller, Jung, Roberts, 2014; Koumans et al., 2005). Results of the ACHA 2013 Pap and STI Survey conducted by the ACHA (n = 140) indicated 87.9% of institutions distribute condoms to their students for free and 36.4% sell condoms on campus (Eastmann-Mueller et al., 2014). A national investigation of 736 schools by Koumans and colleagues (2005) revealed 52% of institutions distribute condoms to students, including 74% of schools with a health center. A recent assessment of 358 colleges and universities with student health centers by Butler and colleagues (2011a) indicated 84.9% of student health centers distribute condoms to students, with the mean of 9,414 condoms distributed/year. Select campus demographics have been found to significantly predict sexuality-related service availability at colleges and universities (Butler, Black, & Avery, 2012: McCarthy, 2002; Miller, 2011) including sponsoring of a condom distribution program (Butler et al., 2011a; Koumans et al., 2005).

The Transtheoretical Model (TM) and the Health Belief Model (HBM) are common theoretical foundations used to guide public health interventions and assess individual-level risk of disease acquisition (Champion & Skinner, 2008; Prochaska, Redding, & Evers, 2008). Recently the TM and HBM have been used to assess institutional and organizational behavior (Leversque, Prochaska, & Prochaska, 1999; Price & Oden, 1999), sexuality-related services at colleges and universities (McCarthy, 2002), and university health policies (Reindl, Glassman, Price, Dake, & Yingling, 2014). McCarthy (2002) used the TM and the HBM to assess emergency contraceptive pill (ECP) availability among 358 college health centers nationally. Results indicated the majority of schools were in the maintenance stage (defined as having distributed ECP to students for 1 to 5 years) and the most common institutional benefits associated with distribution included prevention of pregnancy (97.3%), student appreciation (71.1%), and linking ECP with other traditional forms of contraception (59.4%).

Over the past 40 years, the Diffusion of Innovations Theory (DIT) has been used as a framework in over 5,200 empirical investigations (Rogers, 2003). The DIT can be applied to both individuals and the adoption of innovations by organizations (Rogers, 2003). Since its inception, the DIT has been used in various public health settings and has been applied to interventions designed to reduce risk of HIV (Haider & Kreps, 2004; Bertrand, 2008). Institutional complexity and institutional size are two constructs of the DIT which are hypothesized to positively correlate with organizational innovation (Rogers, 2003). Rogers (2003) defines complexity as the “degree to which an organization’s members possess a relatively high level of knowledge and expertise, usually measured by the member’s number of occupational specialties and their degree of professionalism (expressed by formal training)” (p.412). While the number of college and university employees who participate in condom distribution programs is unknown, previous research has indicated student peer educators have participated in distribution efforts (Butler & Black, 2001; Butler et al., 2011a; Butler, Hartzell, Przybyla, & Bickers-Bock, 2006). Despite the importance of condom availability and prevalence of condom distribution programs on college campuses, no previous investigation has used a theoretical framework to assess condom distribution programs from an institutional perspective.

The purpose of the present study was to assess college and university condom distribution programs using constructs of the TM, the HBM, and the DIT. Specifically, the foci of the study were six fold and were designed to assess the following (a) institutional stage of change associated with condom programs, (b) frequency of institutional barriers and benefits associated with condom programs, (c) relationship between the presence of a condom distribution program and institutional benefits and barriers, (d) relationship between campus demographics and institutional barriers, benefits, and complexity, (e) relationship between the number of condoms distributed/year and number of students, number of health center employees, institutional benefits, barriers, and institutional complexity, and (f) prevalence of college and university employees and student peer helpers/educators who are involved with condom distribution programs.

Method

Participants

Four hundred thirty-eight participants (39.8% response rate) who served as their campus ACHA representative or the director of student health services department completed questionnaires regarding their institution’s condom and safer sex product-related services. Institutionally, the participants resided in 47 U.S. states and Washington D.C. The sum student population of participating institutions was 4.8 million. The mean student population was 11,126 (SD = 12,680, Mdn = 6,000, and Mo = 12,000). The mean number of health center employees was 26.28 (SD = 46.62, Mdn = 9, Mo = 5).

Additional regional, institutional, and student population demographics are contained in Table 1.

Data were collected as part of a large national assessment of condom and safer sex product availability among U.S. colleges and universities [see Butler, Procopio, Ragan, Funke, & Black (2014) for an additional report on condom and safer sex product availability and Butler, Procopio, Ragan, Funke, & Black (2011) for a report on schools in rural areas]. All recruitment procedures were approved by the campus Institutional Review Board at Georgia College. A previous statistical power assessment by Butler and colleagues (2011a) conducted on colleges and universities nationally indicated a sample size of > 358 would be necessary for the present investigation. To meet this minimum requirement, a sampling frame of 1,101 colleges and universities was identified. To be consistent with the previous condom availability investigation conducted by Butler and colleagues (2011a), a list of 759 institutional members of the ACHA) was procured. This list was supplemented with 342 schools that were randomly stratified from the Peterson’s Guide to Four-Year Colleges (2006). Initially, consent forms and a copy of the Institutional Condom Assessment Questionnaire (ICAQ) were mailed to each of the 1,101 selected institutions. An additional reminder card was mailed was sent to those who had not responded to previous recruitment efforts. All potential participants who had not previously responded to recruitment efforts received a final reminder email two weeks after the initial contact.

Measures

The participants completed the ICAQ developed by Butler and colleagues (2011b). The ICAQ is a theoretically-framed valid and reliable instrument designed to evaluate condom distribution programs from an institutional perspective. Contained within the ICAQ are the precontemplation (2 items), contemplation (1 item), preparation (1 item), and action/maintenance (1 item) constructs from the TM, the institutional benefits (16 items) and institutional barriers (24 items) constructs from the HBM, and the institutional complexity (2 items), and institutional size (2 items) constructs of the DIT. In addition, the ICAQ contains 10 items assessing school demographics. Previous psychometric analyses of the ICAQ by Butler and colleagues (2011b) indicated the overall internal consistency of the instrument was .93 with individual section reliabilities from .60 - .93. Split-half reliability analyses were conducted on the ICAQ by dividing the instrument into two parts (Cronbach alphas of .78 and .92, respectively). The correlation between the two parts was .66, the Spearman-Brown Coefficient value was .79 for both equal and unequal lengths, and the Guttman Split-Half Coefficient value was .72. A test-retest consistency assessment was conducted on the ICAQ by having a subsample of 32 university student health service department employees complete the questionnaire on two occasions. Results indicated the test-retest consistency across all service-related items was 89.6%. For additional information regarding the validity and reliability of the ICAQ, see Butler and colleagues (2011b).

Colleges and universities that have considered offering to students in the past but decided against it and those that previously sponsored a program were coded as being in the precontemplation stage of the TM. Those who were currently considering a program or preparing to implement a program were coded as being in the contemplation and preparation stages, respectively. Finally, schools that had implemented a program less than one year ago were coded as in the action stage and those who currently sponsored a program for more than one year as in maintenance. The institutional benefits construct of the HBM was assessed through the following question: “In your opinion, what are the benefits to offering a condom distribution program on your campus.” Participants were given a list of 16 items representing potential benefits to their program for which they responded yes by checking the appropriate box or no by leaving it blank. The institutional barriers construct was assessed through one question which assessed reasons for not publicizing the program among those which sponsored a program and a second question which read: “In your opinion, what are the barriers/challenges to offering a condom distribution program on your campus?” Participants were given a list of 9 items which assessed reasons for not publicizing their program as well as a list of 16 items which assessed institutional barriers to sponsoring a program. Participants could respond to individual items by checking the appropriate box for a yes response or no by leaving it blank.

The institutional complexity construct of the ICAQ contains two questions, one of which assesses university staff/volunteers involved with condom issues on campus through “giving condoms to students, meeting with students regarding condom use, teaching students about condom use, and/or advocating for condom education/distribution programs” and the second which assesses the use of student peer educators in condom programs through outreach, counseling, and the sponsorship of sexual health events. Institutional size was addressed through two items including one item assessing student population and another on the number of employees at the student health center.

Data Analyses

Descriptive statistics and measures of central tendency were conducted on each of the items of the ICAQ. Each yes response for items of the institutional benefits, institutional barriers, and institutional complexity constructs was assigned a value of 1 and each no response a value of 0. A composite score was created for each construct by summing the values. A mean value of the number of condoms distributed to students/year was computed (for additional data regarding measures of central tendency regarding number of condoms distributed to students/year see Butler et al., 2014). The Spearman Rho correlation was used to assess the relationship between the number of condoms distributed to students per year and the student population and number of health center employee variables as well as the number of condoms distributed/year and the institutional benefits, institutional barriers, and institutional complexity constructs. Univariate and multivariate logistic regression assessments were used to predict the presence of a condom distribution program. Institutional benefits, barriers, and complexity mean comparisons across campus demographics were conducted using ANOVA tests. Simple Chi Squared Tests were used to assess the relationship between campus demographic variables and the use of peer educators in condom initiatives. For these computations, alpha levels for tests of significance were adjusted by dividing .05 by 5 (the number of comparisons for each variable) and alpha was set at .01. Post Hoc mean assessments were conducted using the Tukey HSD test. All data analyses were conducted using SPSS version 22.0.

Results

Transtheoretical Model

Of the 86.3% of colleges and universities that currently sponsor a condom distribution program, 1.3% reported they have been giving condoms to students for less than one year (Action stage). The remainder of the institutions were in the maintenance stage with the majority (68.3%) sponsoring their program for more than 10 years. Nearly one fifth (18.5%) reported having a program for 6 to 10 years and 10.2% reported their program has existed for 1 to 5 years. Only 4 schools reported being in the contemplation stage and one in the preparation. Among those who do not offer condoms to students, 11.9% had considered offering condoms to students in the past but decided against it and 13.4% offered a program in the past and had no intention of implementing a new one.

Reported Reasons for Not Publicizing Condom Availability Among Schools Which Sponsor a Program (n = 88)

n

%

Concerns about creating controversy

21

23.9

Do not want to appear to promote sexual activity

21

23.9

Lack of funding

17

19.3

Administrative objections

15

17.0

Do not want to promote sexual activity

4

4.5

Policy Restrictions

4

4.5

Do not want to promote condom use

1

1.1

Other

33

37.9

Diffusion of Innovations Theory

The mean composite score on the institutional complexity score among all participating institutions was 6.07 (SD = 4.00). Additional data regarding the prevalence of university employees involved in condom programs among schools which sponsor a program are contained in Table 8. Nearly two thirds (63.7%) of all participating institutions use student peer helpers/educators as part of their distribution efforts. See Table 9 for assessment of the prevalence of peer-based condom initiatives across campus demographics. Among schools which use peers in condom initiatives (n = 279), the most common response was the use of peers to give away condoms at campus events (80.6%) and in organizing condom-related events (68.1%) on campus. The least common use was to give away condoms at bars near campus (4.7%) and give away condoms at nearby restaurants (1.4%). Additional uses of peers in campus programming included conducting condom-related outreach (64.9%), counseling on condom-related issues (30.2%), as well as other non-specified uses of peers in condom programs (14.0%).

Table 8

Employees Who are Involved with Condom Issues on College and University Campuses (n = 378)

Note. Means within a demographic variable group sharing a common subscript do not statistically differ at α = .05 according to the Tukey HSD procedure.

Discussion

The present study is the first investigation to use a theoretical framework to assess condom distribution programs within colleges and universities nationally. The multi-level approach using constructs from the TM, HBM, and DIT revealed unique insights into distribution efforts, benefits and barriers to programming, and prevalence of employees who participate in programs or serve as advocates for condom availability. Assessing schools from an institutional perspective is beneficial and extends beyond previous assessments which have been focused upon service availability and excluded key factors within colleges and universities which enable or restrict program efforts. Currently there are no benchmarks for condom distribution programs within college and university settings and there is a dearth of the large-scale assessments needed to enable their creation. The present investigation provides a critical step towards this goal and identifies the need for additional focus upon the influence of campus demographics, employee infrastructure, and policies upon condom availability.

Results indicate the vast majority of colleges and universities sponsor a condom distribution program. Assessment of the TM constructs revealed the majority of the institutions with condom programs report they have been distributing condoms for more than 10 years (maintenance stage). This result corroborates a finding from Koumans and colleagues (2005) whose national assessment revealed that the majority of colleges and universities offer condoms to their students. Overall, condom distribution programs appear to have become an asset in increasing condom availability within higher education schools settings and play a significant role in routine sexual health care. Only four schools were reported in the contemplation stage and one in the preparation stage, which indicates the majority of schools without condom programs have no plans to initiate a program in the near future.

From an institutional viewpoint, condom distribution programs were found to enhance the health of students from a variety of perspectives. While common institutional benefits to programs include the prevention of STIs and reduction of unintended pregnancies, additional benefits were more broadly defined and included encouragement of healthy behaviors and healthy communication among students. These findings indicate the presence of condom availability within schools extend beyond common measures of epidemiological risk. In addition, it is noteworthy that employees believe condom programs provide the best possible care for students and encourage interaction with health care providers. As hypothesized by the HBM, the institutional benefits construct significantly predicts the sponsorship of a campus program and is significantly correlated with the number of condoms given to students/year. While the institutional barriers construct also significantly inversely predicts condom availability, magnitude of the observed effect size was less (OR = 1.740 vs. OR = .598, respectively).

Among schools that offer condoms to students, the most common barriers to distribution were associated with fiscal aspects of program implementation. Among those which do not offer condoms to students, the most common barriers included religious affiliation-based objections, institutional ideology, and administrative objections. While previous assessments of sexuality-related services among U.S. colleges and universities have revealed faith-based schools were less likely to offer select services (Butler et al., 2011a; Butler et al., 2012), the present study is the first to report religious affiliation as a self-identified barrier within these institutions. In addition, nearly one quarter of schools which sponsor a condom program report not advertising condom availability because of concerns of creating controversy. Future research is needed to assess the sexual behaviors and condom use among students who attend faith-based colleges and universities. The identification of these patterns will assist in the development of sexual health care policies and practices tailored to individuals attending these institutions.

Results of the institutional complexity assessments indicate a variety of employees within college and university settings are involved with condom issues on campus and condom distribution efforts. Many schools employed clinical health care providers such as nurses, nurse practitioners, and physicians who are willing to meet with students regarding condom issues. Nearly two thirds employed a university health educator who advocated for condom programs which suggests condom-based programs within some schools are focused upon primary prevention efforts. Additional findings are consistent with previous investigations which found peer educators play a significant role in condom distribution efforts (Butler & Black, 2001; Butler et al., 2011a; Butler et al., 2006). In addition, 72.8% of schools with condom distribution programs identified the student health center director as a professional involved with condom availability. These findings suggest key administrators within college and university settings are necessary for the advocacy of condom programs and the creation of condom-related health policies. Less than one third of all schools with condom programs employed sexuality educators and program coordinators who are involved with condom initiatives. Given the common duties ascribed to these professionals, it can be hypothesized that only the minority of institutions employ these types of individuals. Of the three correlational assessments conducted using constructs of the DIT, institutional complexity was the strongest correlation to the number of condoms given to students/year (r = .630). Finally, complexity assessments indicated significant mean differences across campus demographics with schools with larger student populations reporting more employees who support condom initiatives. On average, faith-based schools employed fewer employees than non-faith-based (6.75 vs 3.14, respectively). Future research is needed to identify the role of key college and university employees in the creation of comprehensive condom distribution programs.

Previous psychometric assessments reveal the ICAQ is a valid and reliable instrument for assessing condom distribution programs among colleges and universities nationally (Butler et al., 2011b). In conjunction with our previous report (see Butler et al., 2014), the present investigation indicates the ICAQ is a useful tool to assess programs including the number of condoms typically distributed to students/year, methods of distribution, demographic predictors of availability, as well as the relationship between availability and theoretical constructs of the TM, HBM, and DIT. The creation of the ICAQ is one step in overcoming the dearth of instruments developed specifically to assess the unique aspects of sexual health care and sexuality-related services within colleges and universities. In the future, the ICAQ can be a useful tool to guide future research designed to assess condom distribution programs and will allow administrators, clinicians, and prevention professionals to compare the efforts within their campus to national benchmarks. In addition, the ICAQ can be used to assess the comprehensiveness of condom availability within individual colleges and universities and may guide future development of health policies.

The present study has limitations to consider. Data procured for the investigation was self-reported by a single individual selected to represent condom distribution efforts for the entire campus. Given the subjectivity of selected theoretical constructs (e.g., perceived institutional benefits and barriers); the reported data may be reflective of one individual’s opinion and not adequately represent the views on campus in their entirety. Nonetheless, selecting the campus health center director or the ACHA designated representative as the study participant may increase the validity of results as these individuals are more likely to be informed of condom distribution efforts and/or author policies regarding condom availability on campus. Future research is needed to assess the opinions and perspectives of a variety of employees on college campuses with regard to condom distribution programs and the benefits/barriers to program implementation.

While the present study met all of the statistical assumptions to ensure the necessary power to enable statistical significance, there may be limitations on the generalizability of specific findings. For example, one key finding reveals religious affiliation as a prevalent institutional barrier to sponsoring condom distribution programs. However, it is noteworthy that only 83 faith-based colleges and universities participated in the investigation. Future research is needed to assess the institutional barriers and benefits within these environments; specifically a large-scale investigation dedicated to faith-based schools is needed to corroborate the findings of the present study and allow greater external validity of findings. Finally, while both the present study and the previous report (Butler et al., 2014) suggest additional efforts are needed to increase the comprehensiveness of condom distribution programs, the effect of these efforts on key public health outcomes such as STI and unintended pregnancy reduction is unknown. Future large-scale collaborative research is needed across college and university campuses to assess the overall impact of condom distribution efforts.

The present study attempts to overcome a significant lack of knowledge regarding the prevalence of college and university condom distribution programs. Results overcome the limitations of previous investigations by providing unique insights into factors that enable or restrict programming. Given the prevalence of condom use among students and the severity of sexuality-related problems among this population, additional large-scale assessments are needed to adequately gauge if the sexual health care needs of college students are being met. Future research should incorporate health behavior theoretical constructs into investigations to overcome the lack of knowledge concerning sexual health service availability and delivery within higher education settings.

References

American College Health Association. (2013). American College Health Association - National college health assessment II: Reference group executive summary spring 2013. Linthicum, MD: American College Health Association.

McCarthy, S. (2002). Availability of emergency contraceptive pills at university and college student health centers. Journal of American College Health, 51, 15-22.

Miller, L.M. (2011). Emergency contraceptive pill (ECP) use and experiences at college health centers in the mid-Atlantic U.S.: Changes since ECP went over-the-counter. Journal of American College Health, 59, 683-689.